This report is a result of a licensure renewal inspection. The physical plant inspection was conducted on January 30, 2023, and the client records review inspection was conducted on February 15, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #4 was admitted on August 24, 2022 and was still active at the time of the inspection. A treatment plan update was completed on November 1, 2022 and the next update was due no later than January 1, 2023; however, there were no updates completed.
Client #5 was admitted on March 17, 2022 and was discharged on September 27, 2022. A treatment plan update was completed on July 22, 2022 and the next update was due no later than September 22, 2022; however, there were no updates completed.
Client #6 was admitted on March 15, 2022 and was discharged on July 11, 2022. A treatment plan update was completed on April 12, 2022 and the next update was due no later than June 12, 2022; however, it was completed on June 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A treatment plan update was completed for Client #4 on 2/16/23. The Director of Implementation for Outpatient Services will be providing re-education to all clinical staff regarding treatment plan timeframes during a staff meeting being held on 4/3/23. The facility's Office Administrator will be responsible for ongoing compliance and will track the completion of treatment plan updates for all clients. The Office Administrator will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |